Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

The case involved a 63 year old man who went in to see his primary care physician. He was receiving psychotherapy, but was still prone to anxiety. The PCP prescribed him alprazolam for the anxiety. Since the clinic had just implemented a new e-prescribing system, the doctor assured the patient that he didn’t need a paper prescription and just needed to show up at pharmacy and pick up his order.

So far so good.

Back at the doctor’s office, a nurse entered the presribed medication into the practice’s shiny new system, except that she inadvertently added an order of atenolol, intended for a different patient, to this patient’s order. She soon realized her mistake and deleted the atenolol order.

When the patient went to the pharmacy, he was given both the alprazolam and the atenolol, which he thought was odd, since he had been prescribed only one medication. However, he just went ahead with taking both medications per the directions handed to him by the pharmacist, and it was only a few days later, during an appointment with a cardiologist that the mistaken atenolol addition was finally identified.

Fortunately, the patient lived to tell the tale, which we all know is not the outcome in some sad cases. Elisa W. Ashton, the author of this Cases and Commentaries piece, has some great points listed as her takeaways from this case. Here are mine:

– It’s too soon to say goodbye to paper. I worry about trees more than the average Jane, but if there’s a ever a case to be made for a paper prescription, here it is. A paper prescription would’ve shown up the double prescription both to the nurse, as well as the patient, making it less likely to make it to the pharmacy.

– It’s not clear who/what failed. Did the nurse realize delete the wrong entry only after she transmitted the patient’s prescription? Did the prescription software trule delete the medication or simply mark it as flagged for deletion?

– This accident happened on a newish system, perhaps users were not as familiar with it as they should have been.

– If you think something’s odd about your prescription, speak up. As patients many of us tend to assume that doctors know best. However, doctors are as human as everyone else, no matter how many initials tag along before or after their names. You don’t have to be obnoxious about it, it’s perfectly fine to verify politely with your doctor’s office if the additional (or missing) medications are necessary.

– Bravo to the eagle-eyed cardiologist! It was great someone caught this error in time, though I would much prefer that some kind of check system be built into the e-prescription system to prevent errors of this sort.